Strongyloides hyper-infection in a lung transplant recipient: Case report and review of the literature.

CASE PRESENTATION: A 63-year-old man with a left single lung transplant for end-stage combined restrictive and obstructive lung disease developed persistent pulmonary infiltrates and recurrent gram-negative bacteremia post-transplant. Bronchoalveolar lavage fluid revealed a nematode on Papanicolau staining compatible with Strongyloides stercoralis larvae on day 50 post-transplant. Although Strongyloides serology performed post-transplant was negative, a retrospective review of the medical record revealed marked peripheral blood eosinophilia on several occasions before transplantation. Despite reduction in immunosuppression and treatment with albendazole and ivermectin, the patient developed another episode of Escherichia coli bacteremia. He died 3 months post-transplant from pulmonary and neurological complications. DIAGNOSIS: Strongyloides hyper-infection. DISCUSSION: Strongyloides hyper-infection syndrome is known to occur in immunocompromised patients, but it has only been reported once in a lung transplant recipient. This case illustrates the importance of screening for parasitic infections before transplantation in patients with marked eosinophilia, especially among immigrants from countries in which Strongyloides is endemic. Hyper-infection syndrome may appear years after infection in the context of immunosuppression or immunodeficiency. This case also highlights the association between Strongyloides hyper-infection and bacteremia with enteric organisms.

PRÉSENTATION DU CAS: Un homme de 63 ans ayant subi une transplantation du poumon gauche à cause d'une pneumopathie en phase terminale à la fois restrictive et obstructive a développé des infiltrats pulmonaires persistants et une bactériémie à Gram négatif récurrente après la transplantation. À la coloration de Papanicolau, le liquide du lavage bronchoalvéolaire a révélé un nématode compatible avec des larves de Strongyloides stercoralis le cinquantième jour après la transplantation. Même si la sérologie du Strongyloides effectuée après la transplantation était négative, une analyse rétrospective de son dossier médical a révélé une éosinophilie sanguine périphérique marquée à plusieurs occasions avant la transplantation. Malgré la diminution de l'immunodépression et un traitement à l'albendazole et à l'ivermectine, le patient a contracté une nouvelle bactériémie à Escherichia coli. Il est décédé de complications pulmonaires et neurologiques trois mois après la transplantation. DIAGNOSTIC: Hyperinfestation à Strongyloides. DISCUSSION: On sait que le syndrome d'hyperinfestation à Strongyloides se déclare chez des patients immunodéprimés, mais il n'a été signalé qu'une fois chez un transplanté du poumon. Ce cas démontre l'importance du dépistage d'infections parasitaires avant la transplantation chez des patients atteints d'éosinophilie marquée, notamment chez des immigrants de pays où le Strongyloides est endémique. Le syndrome d'hyperinfestation peut se manifester des années après l'infection en cas d'immunodépression ou d'immunodéficience. Ce cas fait également ressortir l'association entre l'hyperinfestation à Strongyloides et la bactériémie causée par des organismes entériques.

Impact of Rejection of Low-Quality Wound Swabs on Antimicrobial Prescribing: A Controlled Before-After Study.

In this controlled before-after study, wound swabs were only processed for culture, identification, and susceptibility testing if a quality metric, determined by the Q score, was met. Rejection of low-quality wound swabs resulted in a modest decrease in reflexive antibiotic initiation while reducing laboratory workload and generating few clinician requests.

Predictive utility of swab screening for vancomycin-resistant Enterococcus in selection of empiric antibiotics for Enterococcus sterile-site infections: a retrospective cohort study.

BACKGROUND: Swab screening for vancomycin-resistant Enterococcus (VRE) is used to identify VRE carriers and thus prevent transmission of this organism. We tested whether screening results could have unintended benefits in predicting the vancomycin susceptibility of subsequent Enterococcus infections experienced by these patients. METHODS: We conducted a retrospective cohort study of all patients admitted to a large tertiary care hospital between 2010 and 2015 who underwent swab screening for VRE before experiencing an Enterococcus sterile-site infection. We derived test characteristics using the screening result as the test variable predicting the presence or absence of vancomycin resistance in the sterile-site Enterococcus species. RESULTS: Culture results for sterile-site samples were positive for Enterococcus for 619 patients during the study period. Of these, 488 (79%) had previously undergone VRE screening. A total of 19 (4%) of the 488 screening results were positive for VRE, and 10 (2%) of the sterile-site Enterococcus isolates were resistant to vancomycin. The overall specificity of VRE swabs was 97% (95% confidence interval [CI] 96%-99%), sensitivity was 70% (95% CI 35%-93%), the positive likelihood ratio was 28 (95% CI 14-56), and the negative likelihood ratio was 0.31 (95% CI 0.12-0.79). The post-test probability of vancomycin resistance in a sterile-site culture, given a positive result with VRE screening swab, was 37% using study data and 83% using published aggregate prevalence data for VRE in the United States. INTERPRETATION: Prior VRE screening swab results represent a useful tool for predicting vancomycin resistance in sterile-site Enterococcus infections. Patients with a positive result for VRE screening swab and Enterococcus identified by culture of sterile-site samples should receive empiric treatment with linezolid or daptomycin until sensitivity results are available.

Metabolome remodeling during the acidogenic-solventogenic transition in Clostridium acetobutylicum.

The fermentation carried out by the biofuel producer Clostridium acetobutylicum is characterized by two distinct phases. Acidogenesis occurs during exponential growth and involves the rapid production of acids (acetate and butyrate). Solventogenesis initiates as cell growth slows down and involves the production of solvents (butanol, acetone, and ethanol). Using metabolomics, isotope tracers, and quantitative flux modeling, we have mapped the metabolic changes associated with the acidogenic-solventogenic transition. We observed a remarkably ordered series of metabolite concentration changes, involving almost all of the 114 measured metabolites, as the fermentation progresses from acidogenesis to solventogenesis. The intracellular levels of highly abundant amino acids and upper glycolytic intermediates decrease sharply during this transition. NAD(P)H and nucleotide triphosphates levels also decrease during solventogenesis, while low-energy nucleotides accumulate. These changes in metabolite concentrations are accompanied by large changes in intracellular metabolic fluxes. During solventogenesis, carbon flux into amino acids, as well as flux from pyruvate (the last metabolite in glycolysis) into oxaloacetate, decreases by more than 10-fold. This redirects carbon into acetyl coenzyme A, which cascades into solventogenesis. In addition, the electron-consuming reductive tricarboxylic acid (TCA) cycle is shutdown, while the electron-producing oxidative (clockwise) right side of the TCA cycle remains active. Thus, the solventogenic transition involves global remodeling of metabolism to redirect resources (carbon and reducing power) from biomass production into solvent production.

Boosting autofermentation rates and product yields with sodium stress cycling: application to production of renewable fuels by cyanobacteria.

Sodium concentration cycling was examined as a new strategy for redistributing carbon storage products and increasing autofermentative product yields following photosynthetic carbon fixation in the cyanobacterium Arthrospira (Spirulina) maxima. The salt-tolerant hypercarbonate strain CS-328 was grown in a medium containing 0.24 to 1.24 M sodium, resulting in increased biosynthesis of soluble carbohydrates to up to 50% of the dry weight at 1.24 M sodium. Hypoionic stress during dark anaerobic metabolism (autofermentation) was induced by resuspending filaments in low-sodium (bi)carbonate buffer (0.21 M), which resulted in accelerated autofermentation rates. For cells grown in 1.24 M NaCl, the fermentative yields of acetate, ethanol, and formate increase substantially to 1.56, 0.75, and 1.54 mmol/(g [dry weight] of cells·day), respectively (36-, 121-, and 6-fold increases in rates relative to cells grown in 0.24 M NaCl). Catabolism of endogenous carbohydrate increased by approximately 2-fold upon hypoionic stress. For cultures grown at all salt concentrations, hydrogen was produced, but its yield did not correlate with increased catabolism of soluble carbohydrates. Instead, ethanol excretion becomes a preferred route for fermentative NADH reoxidation, together with intracellular accumulation of reduced products of acetyl coenzyme A (acetyl-CoA) formation when cells are hypoionically stressed. In the absence of hypoionic stress, hydrogen production is a major beneficial pathway for NAD(+) regeneration without wasting carbon intermediates such as ethanol derived from acetyl-CoA. This switch presumably improves the overall cellular economy by retaining carbon within the cell until aerobic conditions return and the acetyl unit can be used for biosynthesis or oxidized via respiration for a much greater energy return.